In Pursuit of the Triple Aim

Case studies of two organizations participating in IHI's Triple Aim initiative shed light on how to improve population health and the patient experience-while also reducing costs.

In October 2007 the Institute for Healthcare Improvement (IHI) launched the Triple Aim initiative, designed to help healthcare organizations improve the health of a population and patients' experience of care (including quality, access, and reliability) while lowering-or at least reducing the rate of increase in-the per capita cost of care. Pursuing these three objectives at once allows healthcare organizations to identify and fix problems, such as poor coordination of care and overuse of medical services. It also helps them focus attention on and redirect resources to activities that have the greatest impact on health.

Without balanced attention to these three overarching aims, healthcare organizations may increase quality at the expense of cost, or vice versa. Alternatively, they may decrease cost while creating a dissatisfying experience for patients. Many problems that healthcare systems face can be linked to one or more of these objectives. Problems like supply-driven care, preventable readmissions, and overbuilding may represent a failure on all three counts.

While easy to understand, the Triple Aim is a challenge to implement. Various forces and traditions have encouraged physicians and hospitals to focus on acute and specialized care over primary and preventive care and to think narrowly about care for particular conditions or episodes of care for individual patients, without considering the health of a population.

Two Case Studies

To achieve the Triple Aim, healthcare organizations must broaden their focus to organize care to meet the needs of a defined population. Payers, especially those with little direct influence on health outcomes and patient satisfaction, find they must forge new kinds of partnerships with providers. Success requires a willingness to take on new roles and a com¬mitment to honest self-appraisal-otherwise it is easy for healthcare organizations to continue to work on objectives that play to their existing strengths and neglect those that do not.

Lessons from organizations that are pursuing the Triple Aim can guide others who wish to undertake or promote transformation in healthcare delivery.

CareOregon. An Oregon-based not-for-profit managed health care plan, CareOregon partnered with safety-net clinics to optimize care for low-income enrollees by developing two innovative programs: a patient-centered medical home initiative in safety-net clinics and a multidisciplinary case management program for members at high risk of poor health outcomes.

The health plan engaged its independent providers in carrying out these programs by creating learning communities through which the providers could acquire, share, and practice techniques to realize the objectives of the Triple Aim. By partnering with healthcare providers to create and pursue a common vision for improving primary care delivery, CareOregon is transforming its role from a payer to an integrator of care on behalf of its members.

Early results include the following:

CareSupport yielded savings of $5,000 per-member, per-year for high-risk patients through better coordination of care, while maintaining or slightly improving their quality of life.

Implementation of patient-centered medical homes in safety-net clinics was associated with improved continuity of care, health screenings, and chronic care management (e.g., 7 percent increases in the proportion of patients with controlled blood pressure and of patients with controlled diabetes during one year).

As a likely result of both interventions, median monthly costs were 9 percent lower for dually eligible patients who received care in medical home pilot sites versus traditional care sites.

Genesys Health System. A not-for-profit integrated health system based in Flint, Mich., Genesys Health System partnered with its affiliated physician-hospital organization and a tax-supported county health plan for the uninsured to develop a model of care known as HealthWorks.

HealthWorks embodies three key elements:

Engaging community-based primary care physicians in a physician-hospital organization that emphasizes the importance of primary care and makes more efficient use of specialty care

Promoting health through the deployment of health navigators, who support patients in adopting healthy lifestyles to prevent and manage chronic disease

Partnering with community organizations to extend the goals of the model to the entire local population

Early results include the following:

A study by General Motors found the automaker spent 26 percent less on health care for enrollees who received services from Genesys-affiliated physicians versus local competitors.

Use of the hospital, emergency department, and high-tech imaging services were lower than state averages for similar physician groups participating in an insurer's pay-for-performance program.

Use of health navigators among low-income, uninsured patients enrolled in a county health plan improved health behaviors of at-risk patients (e.g., 53 percent increase in physical activity among those who were inactive, 17 percent quit rate among smokers, 80 to 90 percent increases in disease self-management by formerly unengaged diabetic patients) and has contributed to a 50 percent reduction in hospital admissions and emergency department visits.

More Innovations to Come

As more organizations adopt the goals of Triple Aim and share unique and successful approaches to the challenging problems of coordination of care, chronic disease management, and preventive health, the program is likely to yield more innovations that can be extended to a variety of settings. With time, evidence is likely to accumulate on the effectiveness of such models in improving population health, controlling costs, and improving patients' experience of care. With that combination of experience and evidence, the programs they have pioneered may become more commonplace.

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